Healthcare Provider Details

I. General information

NPI: 1326094871
Provider Name (Legal Business Name): ERIC GEWOLB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 KENNEDY BLVD
BAYONNE NJ
07002-2872
US

IV. Provider business mailing address

830 KENNEDY BLVD
BAYONNE NJ
07002-2872
US

V. Phone/Fax

Practice location:
  • Phone: 201-339-0200
  • Fax:
Mailing address:
  • Phone: 201-339-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA03446400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: